- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,496.00 / $4,964.00 / $7,119.04
| Facility | | $3,496.00 | $4,964.00 | $7,119.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $862.49 / $1,326.72 / $2,848.18
| Professional | | $862.49 | $1,326.72 | $2,848.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,415.60 / $2,263.51 / $20,063.05
| Facility | | $1,415.60 | $2,263.51 | $20,063.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,406.00 / $2,263.51 / $16,713.82
| Facility | | $1,406.00 | $2,263.51 | $16,713.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,220.00 / $9,259.00 / $14,242.22
| Facility | | $8,220.00 | $9,259.00 | $14,242.22 |